Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Origins of the Dope Mnemonic

Over at EMCrit, there is an explanation of the Origins of the Dope Mnemonic.[1]

What is DOPE?

When dealing with an intubated patient, when something suddenly changes, that change is usually not a positive change. If the change were a positive change, we would be less worried about figuring out and correcting the change quickly, because when things getting better we do not usually need to correct them.

When an intubated patient suddenly becomes noticeably worse, we need to identify and correct the problem quickly. The reason is simple. The things that cause such a sudden change in presentation are usually preventing the patient from breathing well enough to continue to live. The patient is suffocating.

How does a DOPE help?

It is a simple word that is supposed to remind us of the causes that need to be eliminated, when treating the patient.

DDislodged. The oxygen pipe (endotracheal tube) is not connected to the lung pipe (trachea or windpipe)

OObstructed. The oxygen pipe is no longer delivering oxygen due to a blockage, or there could be a blockage in one of the lung pipes.

PPneumothorax. Not just any pneumothorax, but a tension pneumothorax, but T wasn’t going to work in the mnemonic. The pressure in the chest, due to an expanding airspace outside of the lung, pressing not just on both lungs, but on the heart and on the major blood vessels is causing a rather complex problem with a simple solution. This expanding air space in the chest is preventing the lungs and heart from working properly, even though the oxygen is being delivered. The problem is not with the pipes. The solution is a needle decompression, or (if it will not significantly delay treatment) a chest tube.

EEquipment. While Dislodged and Obstructed tubes can be described as equipment problems, this refers to any of the many problems that do not fall into those two categories (unless what is dislodged or obstructed is within the ventilator). An interruption in the oxygen supply. Anything that causes the ventilator to stop delivering gas under pressure to the endotracheal tube/tracheostomy tube.

There are two easy solutions to these problems, according to PALS (Pediatric Advanced Life Support) from several revisions ago. If the patient is on a ventilator, we can correct three of the four problems by pulling the tube and bagging the patient with a BVM (Bag Valve Mask ventilator). This is aggressive, but effective at eliminating three of the problems. If the patient improves, then it pretty much eliminates the possibility of the fourth problem – tension pneumothorax.

This is aggressive, because we are pulling an endotracheal tube, rather than trying to solve the problem with the endotracheal tube still in place – the people who choose to avoid pulling the tube tend to assume that the tube is in the right place. Sometimes these people are called executioners.

What are the problems with pulling the tube?

The tube will probably have to be placed again, unless there is some reason for not intubating this patient. A sudden need for a crichothyrotomy/tracheotomy may be more likely than a sudden improvement to the point of not needing a tube any more, in a patient who had just suddenly deteriorated, but it is possible.

We should expect to have to intubate this patient again.

If you have read all of what I have written on intubation, you should realize that I do not consider this to be an unimportant decision. Intubation has significant risks.

Should we be hoping that the tube is Dislodged, so that we can justify pulling the tube?

No. It is not important.

Wasting time listening to the lungs again and again and again and again and again . . ., trying to convince ourselves that we can hear breath sounds in the right places, just delays oxygenation of our patient. Our patient who suddenly deteriorated, and is suffocating while we are taking our time trying to figure out what is wrong. Maybe we should look at the chest X-ray that was taken to confirm placement (if we are in the hospital).

This is really simple.

The patient is not breathing.

If we are not delivering oxygen we are allowing the patient to suffocate.

If the problem is any one of the three that can be corrected by pulling the tube and using a BVM to ventilate, then we are suffocating the patient.

What if the tube is obstructed and all we needed to do is leave the tube in place, advance a suction catheter down the tube, spend about ten minutes trying to clear the obstruction (which would probably only occur again in the same place), while the patient sets a world record for holding his breath for ten minutes?

This is suffocating the patient just as much as if we leave a dislodged tube in place and continue to ventilate the stomach, while we listen to lungs sounds referred from the stomach.

What if this is an equipment problem and the tube is in the right place?

If there is a good reason for believing that we hooked the patient up to a faulty ventilator, shouldn’t we have used a different ventilator to begin with?

If we think that the problem is the ventilator and that the patient can continue to go without oxygen without getting worse if we are wrong, then it may be reasonable to switch to bagging through the suspect endotracheal tube, rather than through a mask. It is not unusual for the mask to be out of reach, so bagging through the tube a couple of times, while someone grabs the mask, may be reasonable.

Did the patient improve during those couple of breaths? If not, pull the tube, don’t make excuses for giving the oxygen time to work. Oxygen works very quickly, just as the elimination of oxygen works very quickly. If this patient does not start improving within a couple of breaths, then there is no reason to presume that the endotracheal tube is delivering oxygen to the lungs.

An obstruction should be easy to recognize. When we squeeze the bag, the bag does not deflate the way it should. An esophageal intubation is not as easy to recognize, but the first place to listen is over the stomach to try to hear the gurgling of air being forced into the stomach. If the patient has an empty stomach, which is something anesthesiologists like, it may not make the sounds we expect from an esophageal intubation. If the tube is in the airway, but not definitely in the trachea or in the esophagus, that may also be difficult to recognize.

What if we pull the tube, and bag the patient with a BVM, but the patient does not get better?

Unless we have a really good reason for believing that there is no tension pneumothorax, and Ick factor is not a good reason, we need to decompress the chest on the side that seems quieter. If that does not seem obvious, we should just pick a side. If that does not work, then we should decompress the other side, too.

If this seems extreme, then we should have been assessing for signs of a tension pneumothorax all along, and we certainly should have.

If one feels this is too aggressive an approach, perhaps a career change to chartered accountancy is in order.

Chartered accountancy has fewer true life and death situations where a lack of aggressive action will lead to death.

These are not common in medicine, either, but if we are not ready to deal with them, they will consistently lead to the death of the patient, while we twiddle our metaphorical thumbs.

If DOPE is not something that is politically acceptable, then POET might be a useful mnemonic.

PPneumothorax (tension pneumothorax).

OObstructed.

EEquipment.

TTube (dislodged).

there are a lot of ways that this is a less effective mnemonic. Is T for Tube of for Tension pneumothorax? If T is for Tension pneumothorax, then what is the P for? At least it is politically correct and the road to the morgue is paved with politically correct speech.

Because I could not stop for Death,
He kindly stopped for me;
[2]

That is, to quote a POET.

Avoiding aggressive action, because of What if . . . ? will not prevent the patient from having a bad outcome, unless we change our terminology so that death is a good outcome. The not politically correct George Orwell would understand.[3]

Footnotes:

[1] Origins of the Dope Mnemonic
by EMCRIT on JANUARY 24, 2011
Article

[2] Death
Emily Dickinson
Poem

[3] Doublespeak
Wikipedia
Article

.

Comments

  1. Dr. Weingart and your post couldn’t have better timing. We recently have had some EMT-Intermediate students at the station, and none of them had been taught this mnemonic! Nor, when given simple scenarios involving the four, did they have a systematic approach to identifying the root cause.

    Seems odd to teach intubation but not teach DOPE. Was pretty neat to get the background on the mnemonic device.

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